Download Macmillan Aftercare Rehabilitation Team (Surrey) – Mars (Anne Hope)

MACMILLAN AFTERCARE
REHABILITATION TEAM
(MARS)
Anne Hope
Head and Neck CNS.
Background to MARS
• Lack of local specialist aftercare services in
Surrey/Hampshire/Sussex
• Non- compliant with National /local policies and
guidelines, e.g. (NICE, 2004)
• Post treatment HNC patients lacked local support in
rehabilitation and support following treatment.
• Number of cancer survivors growing
• Inconsistent access to support services and specialist
follow up across cancer alliance.
AIMS OF THE MARS TEAM
• To provide a multi-disciplinary, holistic specialist
service to HNC patients and their families
throughout follow up.
• To provide follow up closer to patients home.
• To promote self management in a supportive
environment and facilitate/sign post to local
support services.
• To meet national and local policies and guidelines
on cancer survivorship and rehabilitation.
MARS OBJECTIVES
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Improve patient and career experience.
Facilitates patient choice.
Reduce avoidable / inappropriate hospital admissions.
Reduce post surgical treatment complications, e.g.
chest infections/tube site infections.
• Reduce oral and enteral nutritional supplementation
through SALT/dietetic.
• Proactive support for laryngectomy patients reducing
emergency laryngectomy replacements and support
self management of laryngectomy and stoma.
Planning of MARS
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Discussions with local PCT’S
Time line devised on clinical activity and need.
Models of potential teams devised
Support and funding obtained from Macmillan
Cancer Support
• Steering group commenced.
• Discussions with commissioners.
Head and Neck Cancer Diagnosis
and Treatment at RSCH
Feeding
tube
insertion
Treatment Completed at RSCH
(Surgery, Chemoradiation, Radiotherapy)
Holistic
Needs
Assessment
Final Multidisciplinary Clinic
Clear scan and/or histology
Referred to Local Hospital for
Consultant and MARS team review
Nutrition
Nurse
Dietitian
Speech
Therapist
Care Support
Worker
Advice and on-going support/referral
onto other services as required
Referral back to acute MDT for patients with
recurrence, further treatment, palliation
NEW PATIENTS REFERRED FOR TREATMENT TO CANCER CENTRE
(Surgery/Radiotherapy/Chemo-radiation /palliative care)
RT/CRT
Followed up at centre
3/12
Surgery @RSCH
Palliative Care
No further treatment –
refer to MARS
PORT/CRT
Palliative Treatment
@RSCH
Disease recurrence –refer to
MDT @RSCH
On completion of palliative treatment
refer to MARS / Local Palliative care
services
Benefits of MARS
• More effective clinics at Cancer Centre.
• Improved patient/carer experience.
• Multi-disciplinary team approach for
rehabilitation and cancer survivorship locally.
• Reduced admissions for SVR emergencies.
Reduce rate of feeding tube infections.
• Reduction in the cost nutritional supplements
in the community.
CHALLENGES
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Funding
Fixed term contracts
Band 4 role
Referral to MARS
Clinic space
Continuity/productivity of clinics in locality
What would we do differently?
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Team leader ?
Avoid fixed term contracts
Tariff based?
Include nurses in team.
Include admin role.
THANK YOU
Any Questions ?